Learning sites for health systems research: Reflections on five programs in Africa, Asia, and Central America

Introduction
Learning sites have supported intervention development and testing in health care, but studies reflecting on lessons relating to their deployment for health policy and system research (HPSR) in low- and middle-income settings are limited.

Methods
This experience report draws from learning over three continents and five research and community engagement programs—the oldest starting in 2010—to reflect on the challenges and benefits of doing embedded HPSR in learning sites, and how those have been managed. Its objective is to generate better understanding of their potential and constraints. The report draws from team members' experiential insights and program publications.

Results
Challenges relating to initial engagement in the sites included building and maintaining trust, managing partner expectations, and negotiating priority topics and stakeholders. Once the embedded research was underway, sustaining engagement, and managing power dynamics within the group, supporting all participants in developing new skills and managing rapidly changing settings were important. Finally, the complexity of reflecting on action and assessing impact are outlined, along with potential approaches to managing all of these challenges and the variety of gains that have been noted across the programs.

Conclusions
We highlight the potential of learning sites to develop relationships, capacities, and local innovations which can strengthen health systems in the long term and some lessons in relation to how to do that, including the importance of stable, long-term funding as well as developing and recognizing facilitation skills among researchers. Supporting spaces for learning is particularly important when health systems face resource constraints and everyday or acute stressors and shocks.